Lessons learned from the nursing home industry

A very wise person once told me  culture trumps strategy.  As a social worker and healthcare strategist, this made perfect sense   emphasizing the yin and yang  facings strategy development, budgeting, organizational enhancement, or performance improvement.  Devotees of LEAN, Deming, and the other sundry philosophies to create change all provide varying levels of respect and homage to the notion of culture; yet, they rarely position cultural change as the lynchpin of implementation of any change.

 

The statement,  healthcare as an industry is in a state of change,  is unnecessary – there is no element, business model, or player within the healthcare care delivery system  not in some state of chaos, cultural change, or business model adaptation.  For several years I had the opportunity to work with outstanding clinicians within an integrated delivery system whose original and flagship hospital was slowly dying.  The reason for the death is not germane; the attitude of the staff is the central factor.  As programs left the facility or investment in other sites clearly were made forging a new center of the integrated system, the staff at the original facility maintained that the focus would eventually shift back to them.  Programs lost would be restored.  If they were not restored, the solution to financial and volume terrors was development of new destination services – destination for the consumer community and the integrated delivery system.  The organizational culture allowed, some would argue enabled this thinking, which resulted in continued losses, organizational strife, and a malaise overtaking many of the staff, leaders, volunteers, and governance.  Concurrently the culture could not cope with the death and transition of the site of care.  Each attempt to create change – unit transformation, service delivery modification, physician recruitment, or program development ultimately failed.  All effort was in implementing actions tried at other sites before.  The cultural change needed to parallel the environmental and business systems was never addressed.  Therefore the lack of change was accompanied by name calling, leadership change, and reaching out to lay blame.

 

A recent The Commonwealth Fund issue brief[1] dealt with cultural change and state based nursing home regulation.  A significant amount of research on cultural change permeating decision making was included in their final results.  Citing an example of a system morphing itself through change noted:  “(Pioneer) defines culture change as: “a transformation anchored in values and beliefs that returns control to elders and those who work closest with them.  Its ultimate vision is to create a culture of aging that is life-affirming, satisfying, humane, and meaningful. Culture change can transform a ‘facility’ into a ‘home,’ a ‘resident’ into a ‘person,’ and a ‘schedule’ into a ‘choice.’”[2]

 

The author’s thesis is based on quantitative evidence that perceptions by nursing home providers were guided most often by regulations; and, regulations can impede cultural change.  Several states identified in the study supported and celebrated collaboration between long term care facility providers and regulators resulting in successful cultural change.

 

The Sunday morning political affairs programs on 11 October 2009 brought out political talking heads discussing Afghanistan, gay marriage and the impeding march on Washington, and healthcare.  Senator John McCain was asked if he would vote for healthcare reform when the bill came forward.  Without really answering (don’t forget this is Sunday morning sound bites) he said that it was his belief the Republican Party needed time to create its own reform legislation so that the nation would be provided an alternative.  This presupposes there is a need for debate, alternatives, and options.  Consensus at the federal level is required before moving the discourse into the public sector.  Real cultural change would derive a response that was either consensus driven or developed through consensus.  This statement in essence shouted there will not be agreement and options are required rather than caring for the ill today.

 

The Centers for Medicare and Medicaid (CMS) funded, coauthored, and publicly disseminated a mea­surement tool — Artifacts of Culture Change.  Its purpose is to support providers’ measure their ability to instill cultural, concrete change.  Learning from this 2002 effort, CMS and the Pioneer Network recently published, Creating Home in the Nursing Home: The National Symposium on Culture Change and the Environment Requirements.

 

There is ample evidence offered by the issue brief‘s authors identifying collaboration as an essential element  evoking cultural change.  The process can be slow and methodical or it can strike the right nerve – at the right time, place, and event and be almost immediate.  Noting best practice, The Commonwealth Fund researchers acknowledge allowing cultural change to grow organically within an environment will not evoke the desired results when and where required.    Identifying a program from Oregon State that has regulatory surveyors and nursing home staff paired off for intensive training, this best practice model is seen as a positive step forward.  The key to the Oregon Model is designing and implementing curriculum focused on culture change principles.  Other best practice ingredients in the Oregon model for cultural change include:

 

·         Real-world implementation models.

·         Identifica­tion of real or perceived regulatory barriers, and over­coming such obstacles.

·          Regulatory and nursing home staff shared learning about the other’s culture and how trust can be established.

·         Interdisciplinary learning is facilities by combining regulators, long term care facility staff, consumers — residents and families.

 

The life of a change agent is often short lived – all those invested in the status quo see no need for a change..  The rewards all too often are shared months, years, or longer after implementation.  Positioning the change agent as someone who is leading cultural transformation causes tension, lack of clear verbiage and/or communication, and typically being anointed an organizational scapegoat.  Using the examples put forth by The Commonwealth Fund’s issue brief, dilutes these outcomes because partnership and collaboration breeds shared ownership and responsibility.  It also is endemic of forcing a long timeline on a project.  The reward of blending change into the fabric of the leadership is significant. 

 

The wins learned from several long term care facilities is a positive step forward.  Within the reform debate, or applied to any other change issue, facilitating these elements will smoothen the edges of implementation and avoid hijacking the issue into certain failure:

 

1.    Verbalize the value proposition of both sides in the debate.

 

2.   Identify and facilitate collaborative teams honestly discussing areas of share strength and shared or unique weakness.

 

3.    Establish trust among the partners.

 

4.   Insure accountability and responsibility for success within all sub-groups or parties at the table.

 

5.   Communicate and live the desired cultural change using all your senses.

 

The most rationale, quantitative, needs based strategies can evolve from focus groups, brainstorming sessions, active listening sessions, research, and dialogue.   The budget forms, projections, and proforma will be a work of wonder as a result of these efforts.  If cultural change cannot be verbalized, communicated, and planned for, the opportunity for successful will fall short of goal.  Culture will trump strategy every time.